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0 Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210351 <br /> CalRecycle 181(Rev.10/10) 11 Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C A _ Inspection Type(Fill one) <br /> J <br /> Site Suffix: D I 0 Routine Q Re-inspection Q Referral Q.Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �e�e v�� Cb v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> 'XX YINBusiness or Facility Name 1 Inspected By Inspector <br /> Physical Address <br /> 26S Va` �2CJ•Y1 ��Cw�f --- - <br /> Inspection Date 1 / Q <br /> �oc �SZ O Time In Time Out <br /> Business Rep Title 0 AM t /� O AM <br /> SVy\Ak1 T-60)S I S O PM ' 2 1 lJ PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered N)A <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 4"Other Cc,��4tv� br ,Te,� ` eq <br /> Q�- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> _ a <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> t <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usiness RepTs Signature Phone Number Inspe toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �t) EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />